Improving access to emergency obstetric care in underserved rural Tanzania: a prospective cohort study.

BACKGROUND: One of the key strategies to reducing maternal mortality is provision of emergency obstetric care services. This paper describes the results of improving availability of, and access to emergency obstetric care services in underserved rural Tanzania using associate clinicians. METHODS: A prospective cohort study of emergency obstetric care was implemented in seven health centres in Morogoro region, Tanzania from July 2016 to June 2019. In early 2016, forty-two associate clinicians from five health centres were trained in teams for three months in emergency obstetric care, newborn care and anaesthesia. Two health centres were unexposed to the intervention and served as controls. Following training, virtual teleconsultation, quarterly on-site supportive supervision and continuous mentorship were implemented to reinforce skills and knowledge. RESULTS: The met need for emergency obstetric care increased significantly from 45% (459/1025) at baseline (July 2014 - June 2016) to 119% (2010/1691) during the intervention period (Jul 2016 - June 2019). The met need for emergency obstetric care in the control group also increased from 53% (95% CI 49-58%) to 77% (95% CI 74-80%). Forty maternal deaths occurred during the baseline and intervention periods in the control and intervention health centres. The direct obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6-3.1%) to 1.1% (95% CI 0.7-1.6%) in the intervention group and from 3.3% (95% CI 1.2-7.0%) to 0.8% (95% CI 0.2-1.7%) in the control group. CONCLUSIONS: When emergency obstetric care services are made available the proportion of obstetric complications treated in the facilities increases. However, the effort to scale up emergency obstetric care services in underserved rural areas should be accompanied by strategies to reinforce skills and the referral system.

Scale up and strengthening of comprehensive emergency obstetric and newborn care in Tanzania.

INTRODUCTION: In Tanzania, inadequate access to comprehensive emergency obstetric and newborn care (CEmONC) services is the major bottleneck for perinatal care and results in high maternal and perinatal mortality. From 2015 to 2019, the Accessing Safe Deliveries in Tanzania project was implemented to study how to improve access to CEmONC services in underserved rural areas. METHODS: A five-year longitudinal cohort study was implemented in seven health centres (HCs) and 21 satellite dispensaries in Morogoro region. Five of the health centres received CEmONC interventions and two served as controls. Forty-two associate clinicians from the intervention HCs were trained in teams for three months in CEmONC and anaesthesia. Managers of 20 intervention facilities, members of the district and regional health management teams were trained in leadership and management. Regular supportive supervision was conducted. RESULTS: Interventions resulted in improved responsibility and accountability among managers. In intervention HCs, the mean monthly deliveries increased from 183 (95% CI 174-191) at baseline (July 2014 -June 2016) to 358 (95% CI 328-390) during the intervention period (July 2016 -June 2019). The referral rate to district hospitals in intervention HCs decreased from 6.0% (262/4,392) with 95% CI 5.3-6.7 at baseline to 4.0% (516/12,918) with 95% CI 3.7-4.3 during the intervention period while it increased in the control group from 0.8% (48/5,709) to 1.5% (168/11,233). The obstetric case fatality rate decreased slightly from 1.5% (95% CI 0.6-3.1) at baseline to 1.1% (95% CI 0.7-1.6) during the intervention period (not statistically significant). Active engagement strategies and training in leadership and management resulted in uptake and improvement of CEmONC and anaesthesia curricula, and contributed to scale up of CEmONC at health centre level in the country. CONCLUSIONS: Integration of leadership and managerial capacity building, with CEmONC-specific interventions was associated with health systems strengthening and improved quality of services.

Screening for depression in children and adolescents: a protocol for a systematic review update.

BACKGROUND: Major depressive disorder is common, debilitating, and affects feelings, thoughts, mood, and behaviors. Childhood and adolescence are critical periods for the development of depression and adolescence is marked by an increased incidence of mental health disorders. This protocol outlines the planned scope and methods for a systematic review update that will evaluate the benefits and harms of screening for depression in children and adolescents. METHODS: This review will update a previously published systematic review by Roseman and colleagues. Eligible studies are randomized controlled trials (RCTs) assessing formal screening in primary care to identify children or adolescents not already self-reporting symptoms of, diagnosed with, or treated for depression. If no or only a single RCT is available, we will consider controlled studies without random assignment. Studies of participants with characteristics associated with an elevated risk of depression will be analyzed separately. Outcomes of interest are symptoms of depression, classification of major depressive disorder based on a validated diagnostic interview, suicidality, health-related quality of life, social function, impact on lifestyle behavior (e.g., substance use, school performance, lost time at work, or school), false-positive results, overdiagnosis, overtreatment, labeling, and other harms such as those arising from treatment. We will search MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Library, and grey literature sources. Two reviewers will independently screen the titles and abstracts using the liberal accelerated method. Full-text screening will be performed independently by two reviewers using pre-specified eligibility criteria. Data extraction and risk of bias assessments will be performed independently by two reviewers. Pre-planned analyses, including subgroup and sensitivity analyses, are detailed within this protocol. Two independent reviewers will assess and finalize through consensus the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and prepare GRADE evidence profiles and summary of findings tables for each outcome of interest. DISCUSSION: The systematic review will provide a current state of the evidence of benefits and harms of depression screening in children and adolescents. These findings will be used by the Canadian Task Force on Preventive Health Care to inform the development of recommendations on depression screening. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020150373.

Preterm birth and the future risk of orthopedic fracture.

BACKGROUND: Preterm birth occurs during a critical period of bone mineralization. We assessed whether preterm birth increases the risk of childhood fracture. METHODS: We analyzed a cohort of 788,903 infants born between 2006 and 2016 in Quebec, Canada. The exposure was preterm birth (<37 weeks). The outcome was any future hospitalization for fracture before 2018. We estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association of prematurity with fractures in adjusted Cox regression models. We determined if the risk of facture varied by the child's age. RESULTS: The incidence of fracture hospitalizations was higher in preterm children than in term children (17.9 vs. 15.3 per 10,000 person-years). Compared with term, preterm children had 1.27 times the risk of femur fracture hospitalization (95% CI 1.01-1.60) and 2.27 times the risk of assault-related fractures (95% CI 1.37-3.76). Preterm children had 2.20 times the risk of femur fracture between 6 and 17 months of age (95% CI 1.45-3.35). CONCLUSIONS: Preterm birth is associated with an increased risk of hospitalization for femur fractures and assault-related fractures. Associations are stronger before 18 months of age. Families of preterm children may benefit from counseling and support for fracture prevention during early childhood.

Knowledge acquisition after Helping Babies Survive training in rural Tanzania.

BACKGROUND: While the effectiveness of Helping Babies Breathe (HBB) training in Tanzania has been reported, no published studies of Essential Care for Every Baby (ECEB) and Essential Care for Small Babies (ECSB) in this setting have been found. This study compared knowledge before and after HBB, ECEB and ECSB training in Tanzania. METHODS: Training was provided to future facilitators (n=16) and learners (n=24) in Tanzania. Using standardized multiple-choice questions, knowledge was assessed pre- and post-HBB and ECEB courses for both learners and facilitators, while ECSB assessment was conducted with facilitators only. A >80% score was considered to be a pass. Paired t-tests were used for hypothesis testing. RESULTS: Knowledge significantly improved for both facilitators and learners on HBB and ECEB (p<0.001) and for facilitators on ECSB (p<0.001). After training, learners had difficulty identifying correct responses on one HBB item (21% incorrect) and three ECEB items (25-29% incorrect). After training, facilitators had difficulty identifying correct responses on five ECSB items (22-44% incorrect). CONCLUSIONS: Training improved knowledge in Tanzania, but not sufficiently for feeding, especially for low birthweight babies. Targeted training on feeding is warranted both within the Helping Babies Survive program and in preclinical training to improve knowledge and skill to enhance essential newborn care.

Long-Term Effects of Education and Legislation Enforcement on All-Age Bicycle Helmet Use: A Longitudinal Study.

Bicycle-related injuries are a leading cause of child and youth hospitalizations in Canada. The use of helmets while bicycling reduces the risk of brain injuries. This study investigated the long-term effect of legislation coupled with enforcement to improve helmet use rates. We conducted a longitudinal observational study of helmet use at 9, 11, and 14 years after bicycle helmet legislation was enacted. Data were compared to baseline observations collected after legislation was passed in 1997. A comprehensive enforcement and educational diversion program, Operation Headway-Noggin Knowledge (OP-NK), was developed and implemented in partnership with regional police during the study period. Helmet use was sustained throughout the post-legislation period, from 75.3 % in the year legislation was enacted to 94.2 % 14 years post-legislation. The increase in helmet use was seen among all age groups and genders. Helmet legislation was not associated with changes in bicycle ridership over the study years. OP-NK was associated with improved enforcement efforts as evidenced by the number of tickets issued to noncompliant bicycle riders. This observational study spans a 16-year study period extending from pre-legislation to 14 years post all-age bicycle helmet legislation. Our study results demonstrate that a comprehensive approach that couples education and awareness with ongoing enforcement of helmet legislation is associated with long-term sustained helmet use rates. The diversion program described herein is listed among best practices by the Public Health Agency of Canada.

Maternal depression and malnutrition in children in southwest Uganda: a case control study.

BACKGROUND: Malnutrition remains one of the most significant child health problems in developing countries with an estimated 53% of child deaths per year attributed to being underweight. The 2011 Uganda Demographic and Health Survey (UDHS) showed that 38 % of the children were stunted and 16% were underweight. While dietary and environmental factors are known major contributors to children's nutritional status, maternal depression may also contribute since it disrupts the mothers' ability to cope with demands of childcare. This study aimed to determine the association between maternal depression and malnutrition in children aged one to 5 years in southwest Uganda. METHODS: The study was undertaken between October and December 2014 on children aged one to 5 admitted to the Mbarara regional referral hospital. Cases were malnourished children and controls were children with other chronic conditions but normal nutritional status admitted to the same hospital. Children's ages were recorded, weight and height taken and converted into height for age, weight for height and weight for age and malnutrition was determined based on WHO child growth standards. Mothers of both groups of children were assessed for depression using the depression module of the Mini International Neuropsychiatric Interview (MINI). Participants provided informed consent prior to enrollment. The study was approved by Mbarara University of Science and Technology Research Ethics Committee and funded by MicroResearch. RESULTS: All 166 mothers who were approached agreed to participate in the study. The prevalence of depression among mothers of malnourished children (86 cases) was 42% compared to 12% among mothers of controls (86 controls). The mean age was 25 years (SD 4.43, range 18-40 years). The majority (75%) were married and most were peasant farmers (62%). Maternal depression was significantly associated with malnutrition in children with a crude odds ratio of 2.23 (1.08-1.89) and an adjusted odds ratio of 2.4 (1.11-5.18). CONCLUSION: Maternal depression impacts negatively on child nutrition and development as shown by a higher prevalence of depression among mothers of malnourished children compared to the control group. Routine screening and treatment for depression should be included in all maternal and child health clinics.

Hot Idea or Hot Air: A Systematic Review of Evidence for Two Widely Marketed Youth Suicide Prevention Programs and Recommendations for Implementation.

INTRODUCTION: Youth suicide is highly related to mental disorders. While communities and schools are marketed to with a plethora of suicide prevention programs, they often lack the capacity to choose evidence-based programs. METHODS: We conducted a systematic review of two youth suicide prevention programs to help determine if the quality of evidence available justifies their wide spread dissemination. We searched Medline, PsycINFO, EMBASE, CINAHL, the Cochrane Library, Campbell Collaboration SPECTR database, SocIndex, Sociological Abstracts, Social Services Abstracts, ERIC, Social Work Abstracts, Research Library, and Web of Science, for relevant studies. We included studies/systematic reviews/meta-analysis that evaluated the effectiveness, cost-effectiveness, and/or safety of Signs of Suicide (SOS) and Yellow Ribbon (YR) suicide prevention programs that target adolescents. We applied the Office of Justice Program What Works Repository (OJP-R) to evaluate the quality of the included studies as effective, effective with reservation, promising, inconclusive evidence, insufficient evidence, and ineffective. Two SOS studies were ranked as "inconclusive evidence" based on the OJP-R. One SOS study was ranked as having "insufficient evidence" on OJP-R. The YR study was ranked as "ineffective" using OJP-R. We only included studies in peer-reviewed journals in English and therefore may have missed reports in grey literature or non-English publications. RESULTS: We cannot recommend that schools and communities implement either the SOS or YR suicide prevention programs. Purchasers of these programs should be aware that there is no evidence that their use prevents suicide. CONCLUSIONS: Academics and organizations should not overstate the positive impacts of suicide prevention interventions when the evidence is lacking.

INTRODUCTION: Le suicide chez les adolescents est fortement lié aux troubles mentaux. Bien que les communautés et les écoles soient la cible de la commercialisation d'une foule de programmes de prévention du suicide, elles n'ont souvent pas la capacité de choisir des programmes fondés sur des données probantes. MÉTHODES: Nous avons mené une revue systématique de deux programmes de prévention du suicide pour adolescents afin de déterminer si la qualité des données probantes disponibles en justifie la large diffusion. Nous avons cherché des études pertinentes dans les bases de données Medline, PsycINFO, EMBASE, CINAHL, Cochrane Library, Campbell Collaboration SPECTR, SocIndex, Sociological Abstracts, Social Services Abstracts, ERIC, Social Work Abstracts, Research Library, et Web of Science. Nous avons inclus les études/revues systématiques/méta-analyses qui évaluaient l'efficacité, la rentabilité et/ou la sûreté des programmes de prévention du suicide Signs of Suicide (SOS) et Yellow Ribbon (YR) destinés aux adolescents. Nous avons appliqué le programme du bureau de la justice Ce qui fonctionne (OJP-R) pour évaluer la qualité des études incluses et cotées efficaces, efficaces avec réserve, prometteuses. données non concluantes, données insuffisantes, et inefficaces. Deux études de SOS ont été classées « données non concluantes ¼ selon l'OJP-R. Une étude de SOS a été classée « données insuffisantes ¼ selon l'OJP-R. L'étude de YR a été classée « inefficace ¼ toujours selon l'OJP-R. Nous n'avons inclus que des études de revues en anglais révisées par des pairs et nous avons donc pu rater des études de la littérature grise ou d'une autre langue que l'anglais. RÉSULTATS: Nous ne pouvons pas recommander que les écoles et les communautés mettent en œuvre les programmes de prévention du suicide SOS ou YR. Les acheteurs de ces programmes doivent savoir que rien ne prouve que leur utilisation prévienne le suicide. Conclusions: Les écoles et les organisations ne devraient pas surestimer les effets positifs des interventions de prévention du suicide en l'absence de données probantes.

Early repair of congenital heart disease associated with increased rate of attention deficit hyperactivity disorder symptoms.

BACKGROUND: As more children survive with congenital heart disease, their neurodevelopmental outcomes (including attention deficit hyperactivity disorder [ADHD]) are becoming increasingly important. The objective of our study was to determine if school-aged children who underwent early cardiac surgery for congenital heart disease are more likely than healthy control subjects to have screening scores on the Swanson, Nolan, and Pelham IV (SNAP-IV) questionnaire suggestive of ADHD. METHODS: Children aged 7-15 years who underwent open-heart surgery before 1 year of age were identified from the Izaak Walton Killam (IWK) Children's Heart Centre Database. Control subjects were recruited from healthy volunteers. The SNAP-IV questionnaire was administered to all participants and a chart review was performed on all eligible children in the cardiac surgery group. Case and control subjects were compared using Fisher's exact test, linear, and logistic regression analyses. Potential predictors of a positive screening score were sought. RESULTS: A positive screening score was found in 29% (16/56) of the surgical group compared with 3% (2/60) of the control group (P < 0.001). Surgical and control subjects differed in average overall scores (0.93 vs 0.30; P < 0.001) and in scores for hyperactivity (0.83 vs 0.24; P < 0.001) and inattention (1.04 vs 0.37; P < 0.001). No other significant predictors of a positive screening score were identified. The early open-heart surgery participants who responded to the questionnaire did not differ in baseline characteristics compared with nonresponders. CONCLUSIONS: Children who have open-heart surgery at younger than 1 year of age are more likely than healthy control subjects to have a SNAP-IV score suggestive of ADHD when they reach school age.

The CYRM-12: a brief measure of resilience.

OBJECTIVES: This article details the reduction of the Child and Youth Resilience Measure (CYRM) from a 28-item to a 12-item measure. The CYRM-28 is a measure of youth resilience that accounts for cultural and contextual diversity across youth populations. A reduced version of the CYRM is better suited to inclusion in omnibus surveys. METHODS: Data from two samples of youth from Atlantic Canada are included in the analysis: a) a sample of multiple-service-using youth (n=122; mean age = 18); b) a school-based sample of youth (n=1494; mean age = 15). RESULTS: Three iterations of an Exploratory Factor Analysis were conducted on data from the first sample of youth to identify items for inclusion in the CYRM-12. In the third analysis, a varimax rotated factor analysis of the 12 items resulted in a four-factor solution, with 10 of the items loading well. Reliability of this grouping of questions is satisfactory (α=0.754). Confirmatory factor analysis was then conducted on the second sample of youth. A satisfactory fit was obtained (χ² (51, N=1540) = 255.419, p=0.0001; Adjusted Goodness of Fit Index = 0.960; Comparative Fit Index = 0.957; Root Mean Square Error of Approximation = 0.050). Cronbach's Alpha for the 12 items was also satisfactory (α=0.840). CONCLUSION: Results show sufficient content validity of the CYRM-12 to merit its use as a screener for resilience processes in the lives of adolescents.

Risk factors predisposing to pedestrian road traffic injury in children living in Lima, Peru: a case-control study.

OBJECTIVE: To describe the epidemiology of pedestrian road traffic injury in Lima and to identify associated child-level, family-level, and school travel-related variables. DESIGN: Case-control study. SETTING: The Instituto Nacional de Salud del Niño, the largest paediatric hospital in the city. PARTICIPANTS: Cases were children who presented because of pedestrian road traffic injury. Controls presented with other diagnoses and were matched on age, sex and severity of injury. RESULTS: Low socioeconomic status, low paternal education, traffic exposure during the trip to school, lack of supervision during outside play, and duration of outside play were all statistically significantly associated with case-control status. In multivariate logistic regression, a model combining the lack of supervision during outside play and the number of the streets crossed walking to school best predicted case-control status (p<0.001). CONCLUSIONS: These results emphasise that an assessment of children's play behaviours and school locations should be considered and integrated into any plan for an intervention designed to reduce pedestrian road traffic injury. A child-centred approach will ensure that children derive maximum benefit from sorely needed public health interventions.

Discrepancies between knowledge and practice of childhood motor vehicle occupant safety in Nova Scotia--a population-based study.

OBJECTIVES: To determine discrepancies between knowledge and practice of childhood motor vehicle restraints (CMVRs) and vehicle seating position amongst parents within the province of Nova Scotia. DESIGN: Random telephone survey. SETTING: The Canadian province of Nova Scotia. SUBJECTS: Four hundred and twenty-six households with at least one child under the age of 12 years, totaling 723 children. MAIN OUTCOME MEASURES: The proportion of parents whose children who should be in a specific stage of CMVR and sitting in the rear seat of the vehicle, and who demonstrate correct knowledge of that restraint system and seating position, yet do not use that restraint system/seating position for their child (demonstrate practice discrepant from their knowledge). RESULTS: Awareness of what restraint system to use is good (>80%). However, knowledge of when it is safe to graduate to the next stage is low (30-55%), most marked for when to use a seatbelt alone. Awareness of the importance of sitting in the rear seat of a vehicle was universal. Discrepancies between knowledge and practice were most marked with booster seats and rear-seating of older children. Factors influencing incorrect practice (prematurely graduated to a higher-level restraint system than what is appropriate for age and weight) included lower household income, caregiver education level, and knowledge of when to graduate from forward-facing car seats and booster seats. Incorrect practice was also more commonly observed amongst children of weight and/or age approaching (but not yet reaching) recommended graduation parameters of the appropriate CMVR. CONCLUSIONS: Discrepancies between knowledge and practice are evident through all stages of CMVRs, but most marked with booster seats. The roles of lower socioeconomic status and gaps in CMVR legislation, in influencing discrepant practice, must be acknowledged and suggest the need for targeted education concurrent with development of comprehensive all-stages CMVR policies.

Use of school-based health centres for mental health support in Cape Breton, Nova Scotia.

OBJECTIVE: To determine whether students with self-reported needs for mental health support used school-based health centres (SBHCs) for this purpose. METHOD: A secondary analysis was conducted on self-reported data collected from 1629 high school students from Cape Breton, Nova Scotia. Descriptive statistics and logistic regression analyses were employed to determine the influence of sex, grade, sexual orientation, socioeconomic status (SES), school performance, social involvement, and health risk-taking behaviours on need for mental health support and use of SBHC for that purpose. RESULTS: One-half of surveyed students reported needs for mental health support. Risk for depression was the most commonly reported indicator of need. Only 13% of students visited a SBHC nurse for mental health support, and 4 times as many females than males used the SBHC for this purpose (20.4%, compared with 5.3%, P < 0.001). There was a significantly increased likelihood of use of SBHC for mental health support, given the presence of a greater number of need factors. Multivariate logistic regression determined that female sex (OR 5.57, 95% CI 3.07 to 10.09), lower SES factor (OR 1.19, 95% CI 1.11 to 1.28), sexual health risk-taking behaviours (OR 1.72, 95% CI 1.28 to 2.31), and suicidal behaviour (OR 1.83, 95% CI 1.48 to 2.27) were significantly associated with the use of SBHCs for mental health support. CONCLUSIONS: Substantial need for mental health support and significant unmet need were observed. In particular, male students underused the services relative to their self-reported need. Implications for SBHCs and directions for future research are discussed.

Home visits reduce the number of hazards for childhood home injuries in Karachi, Pakistan: a randomized controlled trial.

BACKGROUND: Although unintentional injuries are major causes of morbidity and mortality in less developed countries, they have received scant attention, and injury prevention policies and programs have just begun to be addressed systemically. AIMS: To reduce hazards associated with home injuries due to falls and ingestions through an injury prevention program administered by home visitors. METHODS: Non-blinded randomized controlled trial design of two interventions where one branch of the study group served as the control for the other in an urban neighborhood in Karachi, Pakistan. The study participants included 340 families with at least one child aged 3 years or less, discharged home from the Emergency Department following a visit for any reason other than an injury. The interventions included: (1) counseling to reduce falls; (2) counseling to reduce poisoning and choking. The primary outcome measure for each intervention was the relative risk of change in the home status from "unsafe" to "safe" after the intervention. RESULTS: There were 170 families in the fall prevention and 170 families in the ingestion prevention branch of the study. The percentage of homes deemed "safe" in which the families had received fall intervention counseling was 13.5% compared to 3.5% in the control group (relative risk 3.8; 95% CI: 1.5 to 10.0; p = 0.002), whereas the percentage of homes deemed "safe" in which the families had received the ingestions intervention counseling was 18.8% compared to 2.4% in the control group (relative risk 7.8; 95% CI: 2.4 to 25.3; p < 0.001). Effectiveness did not depend on education or the socioeconomic status of the study participants. The mean number of fall hazards was reduced from 3.1 at baseline to 2.4 in the fall intervention counseling group, and the mean number of ingestion hazards decreased from 2.3 to 1.9. (p < 0.001). CONCLUSIONS: Our study demonstrates the effectiveness of an educational intervention aimed at improving the home safety practices of families with young children.

Online health promotion, early identification of difficulties, and help seeking in young people.

OBJECTIVE: To examine the use and impact of a dedicated health information Web site for adolescents. METHOD: Five hundred fifty-eight (27.2%) of all students in grades 7 through 12 from 4 schools logged onto the Web site; 1775 (86.4%) of all students in these grades completed a year-end health survey, with 455 (81.5%) of the students who used the Web site completing the survey. Dependent variables were help seeking and satisfaction ratings plus visits to specific Web site sections. Predictor variables were demographic characteristics, mental health, and psychosocial difficulties assessed at years' end. RESULTS: Students logged on >11,000 times during the year. Female students, students wanting professional help, those scoring higher on depressive vulnerability measures, and students reporting more severe mood problems were related to logging on frequently over longer periods of time, as well as viewing information sheets, posting and viewing questions and answers, and completing the symptom screen. Students accessing the Web site from 1 to 7 A.M. reported higher levels of distress than did students who accessed the Web site at other times of the day. Visits to the Web site were positively associated with visits to school health centers and guidance counselors and referrals to a health professional. CONCLUSIONS: Results are consistent with a health-needs model of utilization of this Internet-based health resource. A school-based health information Web site holds significant promise for health promotion and early self-identification for emotional problems.